Pediatric General and Thoracic Surgery San Antonio ... · Pediatric General and Thoracic Surgery San Antonio Pediatric Surgery Associates ... Am. Journal Epidemiology, 1990 ... Microsoft

Pediatrics Grand Rounds 25 September 2009

UT Health Science Center at San Antonio

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Appendicitis

Barry R. Cofer, M.D., F.A.C.S.Pediatric General and Thoracic Surgery

San Antonio Pediatric Surgery Associates

• History• Anatomy and embryology• Demographics• Diagnosis• Treatment• Outcomes

"The appendix n, of the colon n m, is a part of the caecum and is capable of contracting and dilating so that excessive wind does not rupture the caecum."

Leonardo da Vinci FB 14v (1504-1506).

• 1735 – first appendectomy – Claudius Amyand• 1886 – Reginald Fitz – systematic description• 1887 – first U.S. appendectomy – Thomas

Morton• 1889 – Charles McBurney – diagnostic and

surgical technique• 1939 – Wagensteen – obstructive

pathophysiology



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• Develops as diverticulum of the cecum; visible by about 8th week of gestation

• Lymphoid follicles appear by 14th week

• Right lower quadrant location, but may be variable

• Most common cause of surgical abdomen in any age group – 250,000 annually in United States

• Estimated 1,000,000 hospital days• ~ 3-4% of all pediatric ER admissions• Highest rates in the 10-19 year old age

groups• M:F 1.4:1 across all age groups• 8.6% males, 6.7% females lifetime risk

Am. Journal Epidemiology, 1990


• Most common cause of surgical abdomen in any age group – 250,000 annually in United States

• Estimated 1,000,000 hospital days• ~ 3-4% of all pediatric ER admissions• Highest rates in the 10-19 year old age

groups• M:F 1.4:1 across all age groups• 8.6% males, 6.7% females lifetime risk




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Annals of Surgery, 1939

Luminal obstruction

Appendiceal dilation and bacterial overgrowth

Increased luminal pressure/mural tension

Ischemia and necrosis

Appendiceal gangrene and perforation

Symptoms• Abdominal pain• Fever• Nausea/vomiting• Anorexia• Diarrhea• Motion induced pain• Lack of nonsupportive

symptoms

Limitations• Extremes of age• Obesity• Immunosuppression• Altered neurologic status• Abnormal position of

appendix



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Symptoms• Abdominal pain• Fever• Nausea/vomiting• Anorexia• Diarrhea• Motion induced pain• Lack of nonsupportive

symptoms

Limitations• Extremes of age• Obesity• Immunosuppression• Altered neurologic status• Abnormal position of

appendix

• General appearance• Fever• Non-appendicitis

signs• Pain with movement• Abdominal exam• Rectal exam• Gynecologic exam

• CBC• UA• U-HCG as

appropriate



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• Pharyngitis• Lower lobe pneumonia• Sickle cell anemia crises• Vasculitis: HSP, HUS• Bacterial or viral

gastroenteritis• Constipation• Mesenteric adenitis• Omental torsion

• Pancreatitis• Urinary tract infections• Mittelschmerz• Pelvic inflammatory

disease• “Feel bads”

Patient with abdominal pain

Not consistent with appendicitis

Consistent with appendicitis

Not inconsistent with appendicitis

Definitive treatment

Surgical consultation

Surgical intervention?

You are here

… or here ?… or here ?



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Ultrasound• Avoids ionizing radiation• No IV’s or contrast• Highly operator

dependent• Sensitivity 50-100%• Specificity 88-99%• Costs: $ 768 • Not shown to decrease

negative appendectomy rate

Computerized Tomography• First introduced in the

1980’s• Specificity and sensitivity

up to 95%, but varies• Greater accuracy than

U/S• Less radiologist

dependent• Alternative pathologies



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Is it overused?

• Rhea, et. Al (Am J Roentgenol 2005)• 172 pediatric patients with abdominal pain• 138 (80%) underwent CT scan• 62 (45%) negative

• Martin, et. Al. (Journal Pediatric Surgery, 2004)• Three year period; 720 patients• Use of CT increased from 17% to 51%• Negative appendectomy rate and perforation rates

remained the same• 50 negative appendectomies (7%)

• 22% with US diagnosis• 18% with CT diagnosis

Is it overused?

• Wagner, et.al. (Surgery, 2008)• 1425 patients over 7 years (adult and child)• CT use increased from 35% to 95% of patients• Negative appendectomies decreased from 16.3% to

7.6%; almost all adult females• No changes in perforation rate• ~ 76% of patient with normal appendix had positive

CT scan

Is it overused?

• Risks of ionizing radiation• Costs: $ 2,307 (~ $1.4 million/year in SAT)• ? Accuracy in community setting• Does not necessarily protect you from liability• Not shown to decrease pediatric negative

appendectomy rate compared to experienced pediatric surgeon



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Is it overused?

• Risks of ionizing radiation• Costs: $ 2,307 (~ $1.4 million/year in SAT)• ? Accuracy in community setting• Does not necessarily protect you from liability• Not shown to decrease pediatric negative

appendectomy rate compared to experienced pediatric surgeon

Caveats for diagnostic imaging:• Plain films of no value• Not a substitute for clinical diagnosis• Learn how to read your own films• Not more accurate than experienced clinician• Best used where:

• Diagnosis suggests disorder other than appendicitis

• Inexperience with pediatric abdominal conditions• Obese patients, sexually active females,

neurologically compromised patients, extremes of age

• When in doubt, consult experienced surgeon

• 117 (33%) imaging studies prior to surgical evaluation• 60 (17%) imaging studies ordered by surgeon• 220 (62%) underwent appendectomy• 209 (95%) confirmed appendicitis• 66% acute, 34% complicated

SurgicalConsultation

356

Appendectomy195 (55%)

Observation152 (43%)

Discharge Home9 (2%)

Appendectomy25/152 (16%)

Discharge Home127/152 (84%)

Kosloske, et.al., Pediatrics, 2004

Treatment• Non-toxic patients: early appendectomy• Toxic patients: fluid resuscitation, fever control,

broad spectrum antibiotics, followed by appendectomy

• Bacterial flora predominately gram negative, anaerobic• E.coli, enterobacter, klebsiella, pseudomonas• Bacteroides, Clostridia, anaerobic strep

• Antibiotic regimens vary; similar results



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Suspected Appendicitis

Surgical Consultation

Appendicitis confirmed Appendicitis suspected Appendicitis notsuspected

Appendectomy orDiagnostic laparoscopy Imaging Observation Observation or

Discharge home

Imaging

Appendectomy orlaparoscopy

Appendectomy orlaparoscopy

Observation

Acute vs. Complicated Pathology

Acute

N =1105 66%

Perforated

N = 565 34%

Confirmed appendicitis

N = 1069 94%

Other Pathology

N = 51 4.5%

Normal

N = 21 1.8%

Uncomplicated

N = 1514 91%

Wound infection

N = 71 4.2%Intraabdominal

abscess

N = 80 4.8%

Other

N = 5 < 1%



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• Very common disorder, will affect anyone who takes care of children

• Easily managed in early phase of disease; significant morbidity in later phases

• Clinical diagnosis – laboratory studies and imaging are adjuncts only

• Learn to examine the abdomen and read your own films!

• Early surgical consultation and adherence to pathways improve outcome and costs

Σ…

Rev.10/07

The University of Texas Health Science Center at San Antonio

Continuing Education Evaluation Form

Pediatrics Grand Rounds Appendicitis

25 September 2009 – Room 409L MED

Please complete this evaluation questionnaire. Your responses will be used to assess the educational effectiveness of this presentation and to plan future presentations. Define your area of practice (choose all that apply) Educator Researcher Clinician Please select credentials: MD/DO DPM PhD Other:____________

CONFERENCE OUTCOMES – Please indicate the extent to which you were able to achieve the following learning objectives:

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Objective 1: Utilize appropriate diagnostic techniques for the patient with abdominal pain

Objective 2: Appropriately manage cases of simple and complicated appendicitis

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Documents

Pediatric General and Thoracic Surgery San Antonio ... · Pediatric General and Thoracic Surgery San Antonio Pediatric Surgery Associates ... Am. Journal Epidemiology, 1990 ... Microsoft